BURN'S DEPRESSION CHECKLIST
Name
*
First Name
Last Name
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Instructions: Click to indicate how much you have experienced each symptom during the past week, including today. Please answer all 25 items.
Thoughts and Feelings
*
Rows
0
Not At All
1
Somewhat
2
Moderately
3
A Lot
4
Extremely
1 Feeling sad or down in the dumps
2 Feeling unhappy or blue
3 Crying spells or tearfulness
4 Feeling discouraged
5 Feeling hopeless
6 Low self-esteem
7 Feeling worthless or inadequate
8 Guilt or shame
9 Criticizing yourself or blaming others
10 Difficulty making decisions
T&F Calculations
Activities and Personal Relationships
*
Rows
0
Not At All
1
Somewhat
2
Moderately
3
A Lot
4
Extremely
11 Loss of interest in family, friends or colleagues
12 Loneliness
13 Spending less time with family or friends
14 Loss of motivation
15 Loss of interest in work or other activities
16 Avoiding work or other activities
17 Loss of pleasure or satisfaction in life
A&P R Calculations
Physical Symptoms
*
Rows
0
Not At All
1
Somewhat
2
Moderately
3
A Lot
4
Extremely
18 Feeling tired
19 Difficulty sleeping or sleeping too much
20 Decreased or increased appetite
21 Loss of interest in sex
22 Worrying about your health
P S Calculation
Suicidal Urges
*
Rows
0
Not At All
1
Somewhat
2
Moderately
3
A Lot
4
Extremely
23 Do you have any suicidal thoughts?
24 Would you like to end your life?
25 Do you have a plan for harming yourself?
S U Calculations
Your Score on Items 1 - 25 Here:
Total Score
Level of Depression
No Depression
0-5
Normal but unhappy
6-10
Mild Depression
11-25
Moderate Depression
26-50
Severe Depression
51-75
Extreme Depression
76-100
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